Dr. Thomas A. Bowles

Dr. Thomas A. Bowles

NEW PATIENT INFORMATION
Patient Name:
Last Name
First Name
Middle Initial
Preferred Name
Title
Mr/Ms/Mrs/Etc
Gender

Male Female
Family Status

Married Single Child Other
Birth Date

Month Day Year
Date
SS#
Preferred Pharmacy
Pharmacy Name
Preferred Pharmacy: Address
Pharmacy Name
Preferred Pharmacy: Phone Number
Email Address
example@example.com
Home Phone
Mobile Phone
Work Phone
Ext
Address 1
Address 2
City
State
Zip Code
The following is for

the patient the person responsible for payment both not applicable
Employer Name
Phone
Whom may we thank for referring you to our practice?
In an emergency who should be notified? Please enter Emergency Phone number below
Emergency Contact Phone Number
Emergency Contact Name
Responsible Party Information:

This only needs to be filled out if the insurance subscriber is other than patient, or if patient is under 18.
The following is for

the patient's spouse the person responsible for payment both neither-not applicable
Last Name
First Name
Middle Initial
Preferred Name
Title
Mr/Ms/Mrs/Etc
Gender

Male Female
Family Status

Married Single Child Other
Birth Date

Month Day Year
Date
SS#
DL#
Email Address
example@example.com
Home Phone
Mobile Phone
Work Phone
Ext
Address 1
Address 2
Primary Dental Insurance:
Last Name of Insured:
First Name of Insured:
Middle Initial of Insured:
Insured's Birth Date

Month Day Year
Date
ID #
Group #
Address 1
Address 2
City
State
Zip Code
Insured's Employer Name
Patient's relationship to insured

Self Spouse Child Other
Insurance Plan Name
Insurance Address 1
Insurance Address 2
City
State
Zip Code
Secondary Dental Insurance
Last Name of Insured:
First Name of Insured:
Middle Initial of Insured:
Insured's Birth Date

Month Day Year
Date
ID#
Group #
Insured's Address:
Address 2
City
State
Zip Code
Insured's Employer Name
Employer Address
Employer Address 2
State
Zip Code
Patient's relationship to insured

Self Spouse Child Other
Insurance Plan Name
Insurance Address
Address 2
City
State
Zip Code
Insurance Company Phone Number
Medical History
Indicate which of the following conditions you have or have had. By checking the box it will indicate a "YES" response, leaving blank will indicate a "NO" response.

Alzheimer Anemia Arthritis Artificial Joints Asthma Birth Control Pills Blood Disease Blood Thinner Cancer CODIENE COPD DAIRY ALLERGY Defibrillator Diabetes Dizziness Epilepsy Excessive Bleeding Fainting Gag Reflex Glaucoma Growths Hay Fever Head Injuries Heart Disease Heart Murmur Hepatitis Herpes I or II High Blood Pressure HIP SURGERY RODS/PIN HIV Kidney Disease Liver Disease Lyme Disease Mental Disorders MRSA Multiple Medications MVP Nervous Disorders NO DYES Pacemaker Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism SEIZURES Sinus Problems Skin Cancer STD STENTS PLACED Stomach Problems Stroke TREMORS Tuberculosis Tumors Ulcers
Allergies:

Aspirin Codeine Latex Local Anesthetic Penicillin Sulfa Other
If you checked the box marked Allergy Other, provide detailed information
Check all that apply:

Gums bleed when brushing or flossing Treated for gum disease or were told you have lost bone around your teeth Noticed an unpleasant taste or odor in your mouth History of periodontal disease in your family Experienced gum recession Had any teeth become loose on their own (without injury), or have difficulty eating an apple Experienced a burning sensation in your mouth
If any of the checked boxes need further explanation, please describe
List all medications, vitamins and herbal remedies, including regular dosages of asprin
-

Frequent Headaches A smoker or smoked previously FEMALE: Taking birth control pills FEMALE: pregnant
If any conditions or alerts selected above need further clarification, please describe below:
If you are currently under a physician's care, please provide the name and phone number of your physician:
Describe any current medical treatment, impending surgery, or other treatment that may possibly affect you dental treatment.
* By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes.
Notice of Privacy Practices
Dear Valued Patient,

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment and any other healthcare operations that are permitted or required by law.

Effective April 14th, 2003 The Secretary of Health and Human Services passed a new government rule and speculated new regulations regarding the Heath Insurance Portability and Accountability Act (HIPPA) with particular emphasis on the "Privacy Rule". It is our policy to properly determine appropriate use of Personal Health Information (PHI) in accordance with governmental rules, laws and regulations. Our office wants to ensure that our practice never contributes in anyway to the growing problem of improper disclosure of PHI.

By signing the consent you allow your dentist, his staff and others outside our office that may be involved in your care and treatment to use and disclose your PHI for treatment, payment and other healthcare operations. This also implies to others involved in your healthcare such as family, friends, or other persons you may identify that you request to be involved in your healthcare, emergencies or upon professional judgment by the dentist and substantial communication barriers involving the patient and the dentist.

When required by Law, Public Health, Communicable Diseases, Health Oversight, Abuse and Neglect, Legal Proceedings, Law Enforcement, Organ Donors, Funeral Directors, Military Activity, we may use or disclose your Protected Health Information without your consent or authorization.

At any time during your treatment you may refuse to sign the consent in which we may not use or disclose your PHI, we must ask that you state your reasoning in writing. Under this law, if you refuse to disclose your PHI, we have the right to refuse treatment to you. If consent was signed prior to determining refusal of PHI, you may not revoke actions that have already taken place in regards to disclosure of your PHI. At any time you as the patient have the right to request and receive information of certain disclosures of your PHI. At any time you as the patient have the right to request and receive information of certain disclosures we have made regarding your PHI as described in this Notice of Privacy Policy.

As a team we strive to achieve the very highest standards of ethics and integrity in providing service and care to our patients. It is in sincere regards to this plan and our policy to listen to our staff as well as our patients without any thought of penalization if they feel that in an event or instance we are compromising our policy of integrity. We most kindly welcome any input or questions you may have regarding our policy of integrity and want to thank you for being among our most highly valued patients.

Dr. Thomas A. Bowles
HIPPA AUTHORIZATION: PATIENT PHONE/VOICEMAIL/EMAIL CONSENT FORM
Name
Date of Birth

Month Day Year
Date
Address
I hereby give my consent for Thomas A Bowles and Associates (the "Practice") to communicate with me by the communication method listed below unless I "opt out" now or in the future.
TELEPHONE/CELL PHONE/TEXT MESSAGE
I hereby give my consent for the Practice to call me by phone or text message me at the phone number(s) provided below and to leave voice messages and/or to leave a message with the person answering the phone. These messages may be a reminder of my previously booked appointment date and time, or a notification that I need to make an appointment, a payment or other message regarding care provided to me by the Practice.

I have requested that the Practice communicate with me via the method listed above as it is much more convenient for me to obtain updates and messages via such communication method. I acknowledge that the Practice does not have any obligation to provide any messages or updates to me via the communication methods listed above or by any other means in connection with appointment reminders or any other information. On occasion we may send information, newsletter, or promotions to your email. The Practice will never share any of your contact information with 3rd party vendors. It will only be used to communicate with our patients.

I acknowledge that there is no assurance that any such voice message will be transmitted in a secure

Phone numbers for calls/texts/voice messages:
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Work Phone Extension
Email Address
example@example.com
Financial Policy
- Payment is due at the time of service
- We accept the following types of payment: Cash, Credit Card (Mastercard, Visa, American Express, and Discover) and check.
- To avoid an administrative late fee of $75, please make sure changes or cancellations are made at least 48 hours in advance.
- We offer third-party financing through CareCredit
- Returned check fee of $30 will be charged for all returned checks
- As a courtesy, we will file claim forums with your Dental Insurance company. Please remember that insurance is a contract between you, or your employer and the dental insurance company. You are ultimately responsible for payment if for some reason the insurance company does not cover your treatment costs.
- We will provide a treatment plan with insurance estimates prior to treatment. **Estimates of insurance benefits are only Estimates**. Please understand that estimates are based upon the information your insurance company has provided us. Occasionally, your insurance company's determination is different than anticipated.
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Patient Name:

Responsible Party Information:

Primary Dental Insurance:

Secondary Dental Insurance

Medical History

Notice of Privacy Practices

HIPPA AUTHORIZATION: PATIENT PHONE/VOICEMAIL/EMAIL CONSENT FORM

TELEPHONE/CELL PHONE/TEXT MESSAGE

Financial Policy